Published byStanford Medicine

Medical Education

Deep in the basement laboratory of Stanford’s Falk Cardiovascular Research Center, 31 high-school and college students stood in awed silence as surgeon Paul Chang, MD, demonstrated on the room’s large screen how to dissect a pig’s heart. After a moment of watching him point out the valves, atria, ventricles and arteries of the organ, students excitedly grabbed the surgical tools in front of them and began their work.

“This is so cool,” exclaimed Daria Arzy, a student at Harvard-Westlake High School in Los Angeles. “I’m more of a hands-on person, so I really enjoy this kind of thing.”

Department of Medicine Chair Bob Harrington, MD, greeted the participants on their first day and encouraged them to enjoy their time on the Stanford campus. “This is an amazing place,” he shared. “I’m still excited to come to work each day.”

Throughout the course of the two-week program, students learned the foundations of patient care, including how to take a patient’s medical history and vital signs, how to perform a physical exam, and how to administer ultrasounds and injections; practiced surgical techniques; and heard from cardiologists, neurologists, and other experts. “We encountered so many different perspectives,” said Kathy Zhang, a premed student at Vanderbilt University. “It was wonderful to meet medical professionals from different backgrounds and career pursuits.”

During a guest lecture, Chloe Chien, MD, a Stanford medical student graduate and the COO of Homemade, a social healthy cooking program, shared her journey from medical student to startup co-founder. “When I was training to become a surgeon, I suddenly realized that I wanted to help prevent and heal lifestyle diseases like obesity and diabetes,” she said. “So I spoke to patients with chronic diseases to better understand what they were going through.” Chien later engaged the students in a lively discussion about the barriers to healthy lifestyle change, and offered three principles for healthy living: “Cook your own food, listen to your body, and eat whole, natural ingredients.”

On the final day, program organizers handed out certificates and offered their closing remarks to the group: “6 hours in the Stanford anatomy lab, 20 injected oranges, and 31 dissected sheep brains and pig hearts. By any numerical measure, this week has been impressive,” said Program Manager Misty Mazzara. “But this week was never about numbers. It was about bringing bright young students together to introduce them to the practice of medicine.” Eva Weinlander, MD, who co-organized the internship with Sarita Khemani, MD, agreed, adding: “We have been lucky to spend time with all of you. You’ve all been so enthusiastic, professional, and supportive of each other during this journey.”

As the ceremony came to a close, participants lingered in the auditorium — hugging, taking photos, and exchanging contact information. One student echoed the sentiments of many when she yelled: “Don’t worry everyone, I’m coming back next year!”

Lindsey Baker is the communications manager for Stanford’s Department of Medicine. More photos from the internship program can be found on this Flickr page.

Stanford’s Flu Crew, an initiative that gets medical students out into the campus and greater community administering flu vaccines, recently published a paper validating the importance of such initiatives for medical education and public health, and enumerating its best practices so other programs can follow in its footsteps.

Rachel Rizal and Rishi Mediratta were Flu Crew’s co-directors when we first wrote about their work in 2012. Rizal is now a fifth-year student and Mediratta a pediatrics resident at Stanford. They are lead authors on the article, “Galvanizing medical students in the administration of influenza vaccines: the Stanford Flu Crew,” which appears in the journal Advances in Medical Education and Practice.

I learned a lot about Flu Crew in an email exchange with Rizal, Mediratta, and a host of people they said were instrumental in this accomplishment. Catherine Zaw, a Stanford undergraduate who is a co-author on the recent paper, told me,”The Flu Crew concept has already spread to a couple of schools around the Bay Area, including UCSF, and I hope that with the publication of the paper, more medical schools will consider adopting it.”

The article is essentially a blueprint for replicating Flu Crew in other institutions. It describes Flu Crew’s innovative online-based curriculum, created by former Stanford medical student Kelsey Hills-Evans, MD (which she discussed in a post earlier this week). It lays out the planning needed to coordinate vaccination events, which in their case involves the medical school, undergraduate volunteers, the Vaden Student Health Center, Stanford’s Occupational Health Clinic, and community institutions like churches, libraries, and homeless shelters. And finally, it explains the impact on medical students’ attitudes to population health, as one of its main goals as a service-learning program is to provide students with experience in public health and patient interactions early on in their career.

Imee DuBose, MPH, who worked as operations manager at Occupational Health and was inspired by the “impressive professionalism” of Flu Crew’s student leadership to shift her career to student advising, told me: “As a public health professional, I see Flu Crew promoting community health through collaboration, and as a student affairs professional, I see student development and growth – this project combines the best of both worlds.”

Rizal and Mediratta’s successors for the two-year director position, Lauren Pischel and Michael Zhang, were also co-authors. Pischel explained that she thinks public health and preventative medicine are incredibly important in medical education.

“Campaigns like this link the individual you see sitting before you in clinic with the health of the population at large,” she said “I would like to see this paper be used to talk about how we can effectively integrate public health teaching and experience into medical school. There is quite a bit of room to grow in this direction.”

Stanford’s Flu Crew, which administers flu vaccines in and around the Stanford community, has had many successes over the last few years, which we’ll highlight in a post later this week. One achievement I thought deserved special attention is an innovative curriculum on influenza created by former medical student Kelsey Hills-Evans, MD, now an internal medicine resident at Harvard. Her online videos, such as the one above (which is the first in the series), are accessible not only to Flu Crew’s student participants but the public at large.

The videos were produced via a partnership with Khan Academy and built on the flipped classroom model championed by Charles Prober, MD, senior associate dean of medical education. They also received the Shenson Bedside Innovation Award in 2013. Rishi Desai, MD, a Stanford pediatric infectious disease physician and medical fellow at Khan Academy, supervised Hills-Evans’ efforts and told me in an email that Hills-Evans and the Flu Crew “put together some really amazing videos explaining everything from the basics of influenza to common misconceptions and fears that people have about the flu vaccine. They deserve all of the credit for the idea and execution of the project.”

Hills-Evans tried to keep each video under five minutes: “I wanted it to be a quick, high-yield snapshot of information that people could watch in one sitting and not easily forget.” She shared more details with me over email:

What did you aim to convey in these training videos? How did you imagine your audience?

I wanted our student volunteers to come away from the training with enough general knowledge about influenza to answer nearly any question that patients might have. We equipped them with knowledge about its history, how it genetically changes over time, the clinical symptoms, the vaccine’s risks and benefits, specific patient populations, and even a section on flu shot myths. Our last video was meant for students to become public-health advocates equipped with facts and counter-arguments to some of the most common excuses people have for not protecting themselves with the flu vaccine.

For these general info videos, I was really aiming to be accessible to the general public. The topics are all applicable to the lay person, so I tried my best to stay away from clinical jargon. I wanted people to come away from the training with a better understanding of how dangerous influenza can be – many people shrug at the flu as a bit worse than a winter cold, but it kills tens of thousands of people every year. In addition, there are so many myths generated by popular media and the public about the illness itself (i.e., “I got a stomach flu” which is never actually an influenza virus) and especially about vaccines. It was important to me that we make these videos public so more individuals could be informed.

For the sections meant only for clinical personnel, our priority was to train the members of the Stanford Flu Crew, but I also wanted this component to be exportable to other medical programs. It was meant to teach students to deliver the best intramuscular (IM) injections possible. We’ve been told countless times that our method for IM injections yields extremely high patient satisfaction and nearly pain-free injections (some say “the best flu shot they’ve received”).

A recent blog post on Somatosphere sparked my interest in the role that comics can play in the study and delivery of health care, an emerging field called “graphic medicine.” The term was coined by UK-based Ian Williams, MD, who is an artist and independent humanities scholar as well as a physician. He recently launched a website of the same name.

The post introduces a few new books that just came out on the subject: Graphic Medicine Manifesto, a collaborative work by six health-care professionals and humanities scholars, and Ian Williams’ The Bad Doctor. It also describes how comics can open us up to new ways of seeing in ways that text alone cannot:

Comics allow us to ask how we can “orient” ourselves… toward the potentiality of images and away from the systematizing effects of text alone… [Comics use] images and imagistic thinking as a way to see a different mode of existence.

Since it’s an anthropology blog, it suggests that a “graphic medical anthropology” would be a great way to accomplish the anthropologist’s goal of “seeing structure, complexity, nuance, emergence, and multiplicity simultaneously.” We anthropologists often try to achieve this goal with complicated metaphors and theories, but perhaps the old adage about a picture being worth a thousand words holds true in this case.

The post notes that drawings can provide an experience of self-reflection for the artist, and can inspire readers to readily and easily respond with their own experience, making the work more of a dialog. They can introduce “theoretical orientations” in ways that are more accessible, and can expose power relations in ordinary lived experience. Ordinary lived experience is particularly well conveyed by comics; they showcase the mundane and make it meaningful. They can take those “ordinary, chronic and cruddy moments” and convey what it’s like to be part of our society.

Nedelman is chronicling his fellowship experience on his blog. Currently, he is working for the World Health Organization (WHO) in Delhi as part of team responsible for the organization’s media output for the Southeast Asia region. His first entry focuses on the role of media at the WHO and includes a podcast with Vismita Gupta-Smith, a public information and advocacy officer at the WHO in Southeast Asia. Listen to their full conversation above.

Growing up in Kakamega, a rural county in western Kenya, medical technologies and services were extremely limited for Luqman Hodgkinson, PhD. Now a first-year Stanford medical student, Hodgkinson is spending the summer months back in his hometown conducting research and chronicling exciting new developments in medical education – the opening of the first medical school in the region.

With a population of nearly two million, Kakamega is the second largest county in Kenya behind only Nairobi. But with only 12 physician specialists, the vast majority of residents don’t have access to advanced care.

Hodgkinson has received a faculty position as an adjunct associate researcher at the new MMUST School of Medicine and will serve as the designated ambassador from MMUST to Stanford.

As Hodgkinson writes in his first blog entry en route to Kakamega, “Relationships are very important in medicine and this is also true for a medical school that is at the beginning of a bright future.”

His first research project in Kakamega focuses on the efficacy of community outreach programs designed to improve adherence to antiretroviral medications among adults with HIV/AIDS. Under the mentorship of Michele Barry, MD, FACP, senior associate dean for global health at Stanford, Hodgkinson is working with Emusanda Health Centre to evaluate the efficacy of these programs and demographic factors that may impact medication adherence.

He writes in his blog: “Medical research of all kinds is greatly needed in Kakamega to advance the health of the community, particularly in the area of HIV. In Kakamega County, the HIV prevalence is 5.6 percent. Addressing the local HIV pandemic is what inspired me many years ago to pursue medicine and now for the first time I am on my way to join this endeavor.”

Hodgkinson will be blogging from Kakamega throughout the summer, sharing updates from his research activities and collaborative opportunities for members of the Stanford community to get involved with the new MMUST School of Medicine. Follow along on the Center for Innovation in Global Healthwebsite.

These words are all too familiar to Annete Bongiwe Moyo, a senior medical student at the University of Zimbabwe College of Health Sciences in Harare, Zimbabwe, and a former Stanford visiting scholar. In Zimbabwe, where the proportion of men to women in medical school is roughly 3:1, women are encouraged to take up professions as teachers, artists, caregivers – not doctors. And for a woman thinking about becoming a surgeon, well, she might as well keep dreaming.

Though the odds were stacked against her, Moyo made the decision to become a doctor at a very young age. But it wasn’t until she met Stanford surgeon Sherry Wren, MD, that she started to believe that becoming a surgeon was a realistic goal.

The outlook for women in surgery in Zimbabwe is not terribly unlike that in the U.S. when Wren began her residency at Yale University almost 30 years ago. After receiving her medical degree from Loyola University, Wren became the first woman from the university to specialize in surgery. At that time, only 12 percent of surgical residents were women, and the number of women surgeons in the workforce was far less.

But Wren has never let her womanhood hold her back. In fact, her powerhouse personality, fearlessness and passion for her work are the very traits that define her. She has worked all over the world, applying her skill and resourcefulness to provide the best possible care, often with extremely limited resources in remote locations. In many of these places, Wren is often the first woman surgeon anyone has ever seen.

Shocked too was Moyo when Wren appeared on her surgery rotation at the University of Zimbabwe two years ago. Here’s how Moyo recalls their first encounter – one that would have a lasting impact:

[Wren] was a visiting professor in a grand rounds. Medical students are not usually invited to grand rounds, but that day, we were permitted to attend. When the presentation was done, she asked a question, and when she looked my way, she could tell I knew the answer. She called on me, but one of my professors said ‘Wait, she’s a third year student, she may not know what you’re talking about.’ But Prof. Wren insisted, and I answered correctly. So she asked another question, and I got it right. And then another, and I got it right again.

The mood had shifted in the room. No one expected a junior female medical student could be capable of such an eloquent response. No one had ever given her the chance.

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the SMS Unplugged category.

This is the final post in a three-part series on research in medical school. Parts one and two are available here.

In my last two posts, I explored the research paradigm of American medical training. The takeaway was that research requirements may create inefficiencies that have a host of consequences, including an unnecessarily long training process, a potential physician shortage, and an underutilization of talent.

In this post, I’ll lay out a vision for a training process that can produce a more effective physician workforce. The role of a physician has changed over time, and the education system must evolve to keep up. I’ll consider three topics: what students should get out of medical training, how schools and residency programs can help them do it, and how the system at large can enable schools to make changes.

What should students get out of medical training?

First and foremost, medical training should produce doctors who have a strong understanding of human health and disease and have the clinical skills to translate that understanding into patient care. The goal should be to produce good clinicians – that’s what the vast majority of doctors will focus on in their careers.

With that said, I accept the premise that medical training is not exclusively about clinical skills. Physicians are bright, capable individuals, and are uniquely positioned to improve the health status of their patients by other means. Schools should empower their students to pursue those opportunities. For the reasons I discussed in my last post, medical schools have decided that the primary way to do that is through research.

Research is one way to push extraordinarily important advances in medicine, but it isn’t the only way. Doctors can also improve their patients’ health by taking on roles in community health, policy, entrepreneurship or management, among others. These involve many of the same skills and techniques as research, but medical trainees don’t get exposed to these opportunities. We should.

How can schools fulfill this mission?

So how can the education system make this happen? At some point, whether it is in college or medical school, students should be given the flexibility to explore multiple domains of medicine and health care. They should then be able to pick the one or two that fit their interests and pursue them in more depth. Many students will choose to do research, while others will select other specialties. If students explore these opportunities and decide that they would rather focus on being an excellent clinician, that should also be doable.

This would allow physicians to become more effective leaders and decision-makers in the health care system. The traditional training process treats medicine as a universe of clinical practice and research, but the physician workforce has unfulfilled potential across a spectrum of other fields.

I’d been frustrated for a while with how little my patients know about cancer. They come in with all these confusions; they don’t understand the difference between chemotherapy and radiation (and from a doctor’s perspective, there’s a huge difference). They don’t understand our rationale for choosing one treatment or another or a combination. One patient was convinced that hot sauce caused cancer and was really upset that she had gotten cancer because she had gone out of her way to avoid hot sauce all of her life. I realized there is a lot of misinformation out there, and that was the purpose for starting this blog.

My wife and I have two little girls, and in the evenings sometimes they say, ‘Draw dinosaurs with me, Daddy!’ So I started drawing with them, and I enjoyed it so much that I would sometimes stay up at night after they had gone to bed, still working on my dinosaur. My wife saw me enjoying that a lot, and thought maybe I could combine this with educating people about cancer.

Your website is targeted to be generally informative about cancer; why did you start with breast cancer?

Breast cancer is really common in this country, unfortunately, and it’s also very well studied, so we understand a lot about it, which makes it a nice model. There’s a pretty clear algorithm for the proper way to treat a patient with such and such stage breast cancer, so it makes it easy to follow along.

How many characters or episodes are you hoping to do? So far, there’s just “Jane.”

I’m kind of experimenting. I envision that I’m going to follow Jane though her diagnosis and treatment, but my wife told me that Jane can’t die; she really likes Jane. But 40 percent of people with cancer will ultimately die of their disease, so I want to draw and write about what it’s like to be confronting one’s death, at least as I have witnessed it. What can medicine offer those people, and what can’t it? So I want to introduce a character who dies. I feel like there’s so much that’s already happened in Jane’s story, and I could go back and fill in the details. The mutation steps that turn a cell into a cancer cell, that’s actually a really complicated transformation that I could explore in greater depth.

Recent graduates: Never fear if you haven’t picked a career yet; it’s never too late to figure out what you want to do when you grow up. I’m on my third career, and Rahim Nazerali, MD, now an assistant professor of surgery at Stanford, is on his second.

I had a career in international health and I felt like I wasn’t interacting with enough people, I was doing a lot of behind the desk work and I never really interacted with the people I was affecting. I entered medicine for that reason.

And when he entered medical school at Brown University, Nazerali thought he would pursue emergency medicine or orthopedics. But he was wrong again. In the video, he describes a surgery — which he watched on his first day on a plastic surgery rotation — that convinced him that this field was the one for him. Plastic surgeons converted a gaping post-tumor chest hole into a natural looking chest: “You could hardly even tell that anyone was there,” Nazerali said. “At that point, I thought, ‘I want to do that.'”

Now, he’s on the front lines of patient care, where he hopes to stay.

“Many patients come back in after they have their confidence back, after they have their life back, after they have their time with their family back,” Nazerali said. “That’s what makes it really rewarding.”